Acute and Critical Care
2018 February 33(1):43-45 / https://doi.org/10.4266/acc.2018.00080 ISSN 2586-6052 (Print)ㆍISSN 2586-6060 (Online)
■ Editorial ■
Rehabilitation and Intensive Care Unit Deokkyu Kim Department of Anesthesiology and Pain Medicine, Chonbuk National University Hospital, Jeonju, Korea
Critically ill patients frequently experience one or more life-threatening organ failures such as cardiovascular, pulmonary, renal, hepatic failure, etc. Intensive care that focuses on the recovery of these important organs can lead to disregard for relatively less important problems. One of the problems that has been overlooked is the neuromuscular disorder in critically ill patients, and the prevalence of neuromuscular abnormalities and weakness is likely larger than generally considered [1]. Intensive care unit (ICU)-acquired neuromuscular abnormality or ICU-acquired weakness (ICUAW) is related to several factors including long duration of immobility, poor nutritional support, mechanical ventilation, and sepsis. Also, the use of sedative and neuromuscular blocking agent to prevent for fighting against mechanical ventilation cause the limitations of unexpected physical function, resulting in
Deokkyu Kim Department of Anesthesiology and Pain Medicine, Chonbuk National University Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea Tel: +82-63-250-1241 Fax: +82-63-250-1240 E-mail:
[email protected] ORCID Deokkyu Kim https://orcid.org/0000-0001-7613-3529 *No potential conflict of interest relevant to this article was reported.
muscle weakness. In the 1-year study for 109 survivors after acute respiratory distress syndrome, Herridge et al. [2] reported that most patients have extrapulmonary symptoms, which were caused by muscle weakness and fatigue. Only half of the patients in this study were employed at 1 year after the discharge from ICU, and the reasons for unemployment included persistent fatigue, weakness, poor ability to exercise, and functional limitations such as foot drop, immobility of joints, and decreases with the distance walked in the other half the patients. Clinical recovery from acute and critical illness requires several days to weeks, but physical recovery from weight loss, muscle weakness, and physical limitation may require months to years [2,3]. It is also an important point that ICUAW develops at an early phase in patients with mechanical ventilation. Leijten et al. [1] reported that more than half of patients who had mechanical ventilation for more than 7 days developed electrophysiologic abnormalities. Because of early occurrence of weakness and difficulty of recovery, the key of management for ICUAW is considered for prevention and treatment at the same time. The risk factor of ICUAW should be evaluated regularly and minimized as much as possible. The risk factors for ICUAW are as follows: unable to get cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright ⓒ 2018 The Korean Society of Critical Care Medicine
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44 Acute and Critical Care: Vol. 33, No. 1, February 2018
out of bed independently, anticipated long duration of
cation of the two interventions is more effective than the
critical care stay, obvious significant physical or neuro-
one performed alone. In the first study for the effect of
logical injury, lack of cognitive functioning to continue
bedside cycling alone and cycling with MES in Korea,
exercise independently, unable to self-ventilate on 35%
Woo et al. [7] showed that exercise rehabilitation inter-
of oxygen or less, presence of premorbid respiratory or
vention composed of bedside cycling leads to increase of
mobility problems, and unable to mobilize independently
lower limb muscle mass measured by ultrasound. And
over short distances [4]. Patients at risk of ICUAW
they discussed that Korean ICUs don’t have enough hu-
should be immediately identified for what rehabilitation
man resources for rehabilitation such as nursing, respira-
intervention is needed, and the application of interven-
tory, physical therapist, occupational therapist. Compared
tion start as early as clinically possible.
with ambulation, in-bed cycling is very easy to apply to
Application of an early rehabilitation intervention re-
the critically ill patients, and the expected adverse events
quires several considerations about potential barriers,
are few and rare. They expected synergies when addi-
feasibility, safety, and necessary resources [5]. Insuffi-
tional MES was applied; there are no additional benefits
cient human resource, deep sedation and a lack of knowl-
according to MES application. The authors mentioned that
edge regarding benefits to critically ill patients are among
the number of times MES is applied or the degree of
the most important potential barriers to successful appli-
electrical stimulation may not be sufficient to change the
cation of early exercise intervention. Because the system-
muscle mass. Also, the muscle mass was measured di-
ic cooperation among multidisciplinary medical staff and
rectly after the exercise and MES, therefore, temporary
collaborators needed to achieve early rehabilitation, the
increase of perfusion and muscle mass was reflected in
development of ICU-specific protocols and order sets is
ultrasound measurement. Future studies are needed to
required in the busy ICU environment. Traditionally, an
evaluate effectiveness of bedside cycle with muscle elec-
exercise intervention aimed at standing ambulation was
trical stimulation.
performed. For ambulation, especially with mechanically
Potential benefits for patients with early exercise in-
ventilated patients, many staff and equipment are re-
tervention in the ICU include improved muscle strength,
quired. Such equipment includes a portable cardiac mon-
physical function and quality of life. Such exercise re-
itor and pulse oximeter to allow continuous vital sign
habilitation intervention, bedside cycling and muscle
monitoring during ambulation, and a wheeled pole with
electrical stimulation, may also decrease duration of the
infusion pumps for intravenous medications that cannot
length of stay in ICU and hospital stay after discharge
be temporarily stopped during mobilization [6]. A walk-
from ICU, reduce the rate of hospital readmission, and
er, in addition to hands-on assistance from a physical staff,
decrease the use of primary care resources. Furthermore,
provides balance and support during ambulation. A wheel-
the systemic rehabilitation strategies could help patients
chair is generally pushed behind an ambulating ICU pa-
return to their daily life sooner.
tient to permit the patient to immediately sit and rest when necessary, and to transport patients to their room if they become physically incapable of walking due to weakness, fatigue, or medical complications. In recent years, mus-
REFERENCES
cular electrical stimulation (MES) and bedside cyclic er-
1. Leijten FS, Harinck-de Weerd JE, Poortvliet DC, de
gometer are applied because these interventions require
Weerd AW. The role of polyneuropathy in motor con-
less human resource and equipment. The effectiveness of
valescence after prolonged mechanical ventilation.
each method has already been demonstrated in several
JAMA 1995;274:1221-5.
studies; it is still unclear whether the simultaneous appli-
2. Herridge MS, Cheung AM, Tansey CM, Matte-Martyn
https://doi.org/10.4266/acc.2018.00080
Deokkyu Kim. Rehabilitation and Intensive Care Unit 45
A, Diaz-Granados N, Al-Saidi F, et al. One-year out-
bilitation in the intensive care unit: preventing physi-
comes in survivors of the acute respiratory distress
cal and mental health impairments. Curr Phys Med
syndrome. N Engl J Med 2003;348:683-93.
Rehabil Rep 2013;1:307-14.
3. Cheung AM, Tansey CM, Tomlinson G, Diaz-Gra-
6. Needham DM, Truong AD, Fan E. Technology to en-
nados N, Matté A, Barr A, et al. Two-year outcomes,
hance physical rehabilitation of critically ill patients.
health care use, and costs of survivors of acute respi-
Crit Care Med 2009;37(10 Suppl):S436-41.
ratory distress syndrome. Am J Respir Crit Care Med 2006;174:538-44.
7. Woo K, Kim J, Kim HB, Choi H, Kim K, Lee D, et al. The effect of electrical muscle stimulation and
4. National Institute for Health and Care Excellence.
in-bed cycling on muscle strength and mass of me-
Rehabilitation after critical illness in adults. London:
chanically ventilated patients: a pilot study. Acute
NICE; 2009.
Crit Care 2018;33:16-22.
5. Parker A, Sricharoenchai T, Needham DM. Early reha-
https://doi.org/10.4266/acc.2018.00080
